Rochester Institute of Technology RIT Scholar Works
Theses
9-15-1996
Facial rejuvenation with aesthetic surgeries
Landy Lin
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Recommended Citation Lin, Landy, "Facial rejuvenation with aesthetic surgeries" (1996). Thesis. Rochester Institute of Technology. Accessed from
This Thesis is brought to you for free and open access by RIT Scholar Works. It has been accepted for inclusion in Theses by an authorized administrator of RIT Scholar Works. For more information, please contact [email protected]. APPROVALS Rduisor: Robert Wabnitz _ Date: 10- 17'" it,
Rssociate Rduisors:
Raul Herrera M.D. _ Date: ~.~S. 96
~' RalPh~en,ino M.D. Date: 2.(" ....0....;;;.10 _
Department Chairperson: ~uulJn~Shepard ------ I~k!9~ Date: ; /4
I, Landy Lin, prefer to be contacted each time a request for production is made. I can be reached at the following address:
106 Central Park: South Rpt: 15H New York:, NY 10019 Date: /J. . /O·q(O ROCHESTER INSTITUTE OF TECHNOLOGY
A Thesis Submitted to the Faculty of
The College of Fine and Applied Arts
in Candidacy for the Degree of MASTER OF FINE ARTS
Facial Rejuvenation with Aesthetic Surgeries
by
Landy Lin
Date: September 15,1996 ACKNOWLEDGEMENT
Special thanks to my thesis aduisors Professor UJabnitz, Dr. Herrera, Dr. Pennino for their generous help. Hlso thanks to Professor Shepard and Professor Suits for their many ualuable acinic e.
With sincere gratitude to my family: Mom, Dad, Mindy,Wesley and my best friend Chris for their continued support through my academic journey. CONTENTS
Part 1 LUhy Resthetic Surgery ? 1
Part 2
Skin Analysis of the Rging Face 6
Part 3
Rhytidectomy (Face-Lift) 12
Part 4
Blepharoplasty (Eye-Lift) 22
Part 5
Browlift 29
Part 6 37
Retin-R Treatment, Chemical Peel, Dermabrasion and Laser Surgery Conclusion 41
Illustration Techniques 42
Bibliography FOREWORD
In the sixteenth century, Leonardo da Uinci was first to explore human anatomy in his paintings. Combining anatomy ujith art, da Uinci built a bridge between his uiewers and medicine. In modern society, medical illustration still carries the same principle that da Uinci expressed through his art, which is to integrate medicine and art for the betterment of human Hues.
In euolution, one of man's greatest aduances is the increasing knowledge about his physical self which permits aduancement in medical technology. Today, medicine has been reuolutionized to the point where suruiual is no longer the only principle duty, but that it should alleuiate human suffering in all itJs-forms. Surgery is not limited only to the treatment of organic disease but is performed on an electiue basis to improue the quality of life.
Like medical illustrators who unite medicine with art, aesthetic surgeons euerywhere are combining their medical knowledge with their artistic talents to create a better self image for their patients. In our youth oriented society, with the constant improuement of medical technology, people are liuing longer and aging has become a dreadful prospect. While our inner souls remain young, our outer surfaces are aging, causing anxiety about our appearances. Surgery to rejuuenate the most uisible part of our anatomy, our face, could close the discrepancy many of us feel between our youthful inner soul and our aging outer surface. Consequently, happiness may be regained by those who elect to recreate the youthful appearance
through aesthetic surgery. 1 Part One
Why Aesthetic Surgery?
INTRODUCTION
Historically, surgery was usually performed for the remedy of organic diseases. It was considered to be the ultimate procedure for relieuing human sufferings when all other forms of treatment had failed.1 With the constant improvement of medical technology, howeuer, our life expectancy is lengthened greatly and we are slowly emerging from an era where suruiual is the only principal effort. Consequently, we are entering a new age where modern medicine has placed more emphasis on improuing the quality of human life, and is not limited only to the treatment of organic diseases anymore.
In our youth oriented culture, aging has become a dreadful prospect which leads many people to deuelop anxiety ouer their aging faces. Furthermore, as the lifespan lengthens, most people feel energetic long after their appearance begins to deteriorate. It is therefore, aesthetic surgery is undertaken to rejuuenate the patient's appearance, with the ultimate goal to assist positiue psychological modifications. In reality, many claim that the only rationale for performing aesthetic surgery is to improue the patient's psychological well-being.2
1 T. D. Rees, Aesthetic Plastic Surgery, (Phil, W.B. Saunders Company, 1980),pp.21 2 M.T. Edgerton, Psychiatric Considerations. Male Aesthetic Surgery,(St. Louis, The C.V. Mosby Company, 1982), pp 17-38 Figure 1-1 The old us. the young appearance 3 POSITIUE IMPACT with BODV IMAGE CHANGE in AESTHETIC SUAGEAV
The first step in the process of body-image change is the patient's perception of change in appearance as well as sensory changes. The physical sensation that something feels different than before, in addition to seeing that something has changed are psychologically fundamental and prouides a foundation for consequent cognitiue, emotional and behauioral changes.3
Cognitiue changes are ways which patients change their opinions on his/her appearances. Patients undergoing aesthetic surgery often experience an anxious preoccupation with their physical appearance.4 This self consciousness is the experience of self-focused attention, related with negatiue emotions concerning one's self. The most important psychological impact of aesthetic surgery is the reduction in this self consciousness. Clinically, it is steadily recorded that aesthetic surgery reduces the amount of time that patients spend thinking about their appearances.5 This would result in greater amounts of time and emotional energy being focused on other areas of their Hues.
Aesthetic surgery patients often suffer from depression.6 poor self esteem and mild to moderate This is crucial to forming their motiuation for surgery in order to eliminate these aduerse
3 J.M. Goin, Changing the Body.Psychological Effects of Plastic Surgery, (Baltimore, Williams &Wilkens, 1981) pp.131 4 T. Pruzinsky, Collaboration of Plastic Surgeon and Medical Psychotherapist : Elective Cosmetic Surgery. Medical Therapy, 1, 1-13,1988 5 Goin, pp.222 6 Ibid. 4 experiences. The large majority of patients reueal feeling more positiue with their surgically changed appearance and would undergo the procedures again if giuen the choice.7 Patients also feel positiue about the fact that they had the initiatiue to seek out the surgical change. It is uiewed as a uictory ouer age ;they are no longer put in a helpless situation entirely due to circumstances. They feel that they had taken control and made a choice to Wue the second half of their Hues by the same standard as the first.8 Rfter surgery, most patients reported pleasure in hauing finally accomplished something for themselues to increase their self-esteem and self-
efficacy.
Furthermore, when an indiuidual experiences positiue perceptual, cognitiue, and emotional changes after surgery, behauioral changes logically would follow. Patients often become more outgoing and less socially inhibited. Marcus summarizes the process by which the interuention aging process by means of surgery can engender a "domino effect": it would appear that a surgical operation has long term positiue effects and by re leasing preuiously repressed and inacce ssible energies allows the patients to de- uelop a significantly different life-style. This sequence of euents is analogous to
effect"... Leichter's "ripple .(resulting in) increased self-esteem. This in turn may lead to a significant improuement in the life style and the personality of the... patient. (Marcus, 1984, p.317)9
7 Pruzinsky, pp. 1-13 8 J. Ellison, Life's Second Half- The Pleasures of Aging, (Connecticut, The Devin- Adair Company 1978) 9 P. Marcus. Psychological Aspects of Cosmetic Rhinoplasty. Journal of Plastic Surgery, 37, pp. 313-318, 1984 SERIOUS PSVCHOLOGICRL PROBLEMS
The most common but serious psychological complications associated with aesthetic surgery, although rare, are the postoperatiue psychosis and the loss of identity.10 Earlier psycho analytical obseruations had implied that aesthetic surgeries could result in the patient's psychological disintegration. Howeuer, clinical experiments haue inuariably prouen such suggestions to be false.
Loss of identity has been reported with rejuuenating surgical procedures.11 Loss of identity applies to the patient's expressiny that he/she does not feel like her self (depersona lization) combined with generalized anxiety.12 In most cases, howeuer, the loss of identity is transient, rarely lasting more than a few months.
10 Goin, pp.232-240 11 Ibid. 12 ibid. 6 Part Two
Skin Rnalysis of the Rging Face
UJRINKLES RND LINES
UJrinkles on the aging face are often the focus of attention for both the patient seeking aesthetic surgery to restore the youthful appearance and the physician who is to correct the problem. There are many different types of wrinkles and causes for them. The broad diuision is into lines and wrinkles.
Lines diuide into creases, folds, and furrows. H crease is a linear depression whose depth does not extend deeper than the dermis.(Fig. 2-1 R) R fold is an eleuation of the skin that includes the dermis and the immediate subcutaneous fat. (Fig. 2-1, B) R furrow, howeuer, is a depression of the skin that includes the dermis and the contiguous subcutaneous fat. (Fig. 2-1, C) Folds and furrows are linear or curuilinear.13 Unlike the lines, wrinkles could cross each other to form a checked appearance. (Fig. 2-2) They are multiple, partial thickness, multidirectional eleuations or depressions in the skin. (Table 2-1)
TABLE 2-1 Morphology of UJrinkles
1. Lines Creases Folds Furroujs 2. UJrinkles
13 S.J. Stegman, Cosmetic Dermotologic Surgery, (Chicago, Year Book Medical Publishers, Inc., 1980), pp. 5 R. CREASE
B. FOLD
C. FURROUJ Figure 2-1 A, B, C, diagrams showing different lines Figure 2-2, diagram of wrinkles
PRIMRRY FRCTORS
The primary factors which contribute to the changes in skin include aging, actinic damage and Boss of subcutaneous support tissues. (Table 2-2) Like all other systems in our body, the skin also is affected by the biological clock. Seueral researches haue shown that the quality of elastin and collagen fibers deteriorates with age.14
The actinic damage caused by the sun is peruasiue to the skin. Ruerse changes are uariable but present in all layers of the skin. Dermal changes could measure from minimal to moderate and to nearly complete substitution with an amorphous mass of degenerated elastic fibers. Furthermore, sun damage also contributes to loss of elasticity and amplifies the mouement and sleep-related lines.
Loss of subcutaneous support tissue, including
14 Stegman, pp.6 9 the subcutaneous fat, bone, and cartilage, is also a primary factor to changes in the skin. The loss of subcutaneous fat from the cheeks and temple is the first typical occurrence of the aging face. Bone loss usually does not occur until the age of sixty years or older and is most prominent around the mouth and chin. Cartilage loss exists in the nose and leads to falling of the tip of the nose.
SECONDRRV FRCTORS
Secondary factors which contribute to the changes in the skin are grauity, facial mouement and sleep position. (Table 2-2) UJhen the skin's elasticity weakens because of natural aging and sun exposure, secondary factors will emerge.15
Creases, folds and furrows can be the gradual result of facial mouement.(Fig. 2-3) They start to appear when the skin starts to loss resilience from age or other factors. Creases can also result from
the position of the head on the pillow when sleeping. (Fig. 2-4) They are ordinarily found on the lateral forehead and begin on top of the eyebrow and stretch diagonally toward the temporal recede of the hairline.
Chemical peel, retin R treatment, dermabrasion and laser surgery are treatments to eliminate lines and wrinkles. They do so by destroying the old epidermis and dermis to encourage a healthier regrow. After these treatments, the healed epidermis will be nearly normal and the papillary dermis is thickened and more collagenous.16
15 Stegman, pp. 8-9 16 ibid. 10 UJhen the increasingly less resilient skin is constantly pulled by the grauitational force, ptotic eyebrows and eyelids along with double chins are formed. (Fig. 2-5) Brow lifts, blepharoplasty and rhytidectomy can be performed to remoue redundant skin and pull the important features upward.
Resthetic surgeries can deliuer extraordinary results, with patients appearing fiue to fifteen years younger than they did before surgery. Howeuer, these operations do not prouide remedy for the cellular mechanisms which are the existent reasons for the aging skin. Euen though aesthetic surgeries can turn back the clock and rejuuenate, no surgery will be able to preuent aging permanently.
TABLE 2-2 Factors that Change the Skin 1. Primary Factors Secondary Factors Inherent aging Grauity Actinic damage Facial mouement Loss of subcutaneous support 11
Fig. 2-4 Sleep Creases
Fig. 2-5 Grauity Changes 12 Part Three
Rhytidectomy
BACKGROUND
Rhytidectomy is commonly known as face lift. It is frequently performed to remoue excess or loose, sagging skin from the face and the neck. (Fig 3-1) The ultimate goal of the operation is to (a) raise sagging cheeks, (b) maintain a smooth contour and tighten the jowl lines, (c) reduce the distinction of buccolabial folds, (d) decrease ouerabundance bulkiness in the submental and ceruical region and (e) prouide eleuation of facial expression lines from the down ward situation to a more youthful postero-superior orientation.17 (Fig 3-2)
SURGICRL PROCEDURE
Rhytidectomy is done first on one side of the face and then on the other. Patient will need to
wash the face and hair with germinicidal soaps preoperatiuely. Following this, surgical incisions are marked and outlined and the hair is secured before the patient is transported to the operating room.
In most cases the incision starts inside the
hairline at the temples with the anterior superior pole, extends downward in a natural line around the earlobe and protracts into the back of the scalp or nape of the neck.(Fig. 3-1)
17 of w.H. Beeson, Aesthetic Surgery the Aging Face, (Toronto, 1986),pp .71 13
Figure 3-1(a) Preoperatiue face showing deep cheek folds, jowls and loose skin on the face and neck, (b) Incision is made on both sides of the face beginning inside of the hairline at the temples, surrounding the earlobe to the lower scalp.
Figure 3-2 Postoperatiue uiew of face, after facial and neck skin are pulled up. 14 SUPERFICIAL MUSCULO-APONEUAOTIC SVSTEM (SMAS)
The SMAS is a cutaneous fascia layer which occurs and stretch from the superficial surface of the frontalis muscle, jqining with the superficial temporal fascia, inferiorly ouer the zygoma, buccal region, parotid gland, and superficial surface of platysma.(Fig. 3-3) This fascia is associated with the muscle of the face and is connected uertically to the more superficial dermis. It is belieued that the facial and ceruical cutaneous layers are closely associated with the SMAS. Therefore, during the tissue alterations related the skin and to aging , the SMAS shift as a unit.18
During rhytidectomy, there are two modalities of manipulating the SMAS as part of the procedure to restore youthful appearance. They are (a) opening the SMAS, dissecting under, pulling it up or up and back, and suturing it in place, and then excise the excess, (b) folding the SMAS and suturing it to other facial layers for fixation. (Fig. 3-4)
LIPOSUCTION
In some cases, fat suctioning is performed during rhytidectomy to remoue accumulations of fat from beneath the chin and neck. The remoual of sagging skin along with the excess fat makes a more effectiue rejuuenation. This procedure is done
with the liposuction cannula which is a blunt- tipped, narrow, long, strong tube that is used to create tunnels just below the skin and to suction the fat away.(Fig. 3-5, A &B)
18 Beeson, pp.73-75 15
Figure 3-3 The SMAS lager extends into the external part of the facial musculature, inuoluing fibers of the frontalis, the risorius, the peripheral part of the orbicularis oculi, and the platysma. Figure 3-4 Bg lifting the SMAS upwards, tension is formed to tighten the structure, therefore improuing the results of face lift 17
R
B
Figure 3-5 underming with the liposuction cannula (A) The mastoid region. (B) The submental region. 18 ILLUSTAATIUE SURGICAL TECHNIQUES OF RHYTIDECTOMY
I. Start the incision at the temporal hairline and continue down and around the ear, and end the incision in the lateral neck. Use hook to eleuate the skin in order to facilitate dissection. 19
2. Start undermining until reaching the mobile fat near the nasolabial fold. At the completion of undermining, place clamps on the superior temple flap and neck flap. 20
10. Pull flaps superiorly and allow to ouerlap the original incision. Excise the excess skin. 21
11. Close wound by suturing. 22 Part Four
Biepharoplasty
During the middle years and beyond, distinctiue aging deviations appear in the eyelids and brows area. The occurrence of extra skin folds, wrinkles, ptosis of the brows and degenerative changes of the skin and orbicularis oculi muscle may initiate the appearance of baggy eyelids and prominent periorbital fat pads.19 These conditions can glue an individual a constant iveary expression and may also affect one's vision.(Fig. 4-1, A,B,C)
Biepharoplasty, also known as the aesthetic eyelid surgery is an operation with procedures for the removai of redundant eyelid skin and
protrusion of orbital fat on the upper and lower lids.20
Figure 4-1,A. Example of patient with excess eyelid skin, protruding fat tissue on the upper eyelid, pouches of fat under the eye and winkle folds of skin around the eye. 19 T.D. Rees, Aesthetic Plastic Surgery, ii, (Philadelphia, W.B. Saunders Company, 1980), pp.463 20 j.c. Fisher, Manuel ofAesthetic Surgery, (N.Y. Springer-Verlag, 1985), pp .51 23
Figure 4-1, B. Figure demonstrating hypertrophg of the orbicularis muscle.
Figure 4-1, C. Figure showing prominent periorbital fat pads 24
SURGICAL PROCEDURES
Eyelid surgery begins ivith the cautious marking of incision lines on the upper and lower eyelid skin. This should be done prior to any medications given to the patient. The upper lid incision is a curved line, 8-IOmm from the lash line in midline and extends beyond the lateral canthus ivhile elevating the broui. The lower lid incision is placed beneath the lid margin in a natural crease, extending from under the punctum medially to the lateral extent of the lower lid. (Fig. 4-2) It should stretch laterally into the skin crease 1-1.5 cm beyond the canthus.21
Biepharoplasty is usually operated on the upper lid first and then the lower lid. UJorking through the incisions, the surgeon disconnects the skin form the fat beneath it .
Then, the redundant fat and skin are eliminated.
Figure 4-2 Incision marks on upper and lower lids
21 Fisher, pp.53 25 SURGICRL TECHNIQUES ILLUSTRATED
Upper Eyelid:
1. Cut the remarked skin
2. Excise the skin.
3. Dissect carefully superior to the orbicularis muscle. 26
v-,-s.*.s.\.^v.'.^v
4. Lift muscle and identify fat pads beneath the septum
orbital.
5. Remoue thin strip of orbicularis muscle alony the entire
length of the egelid.
6. Close the wound with subcuticular sutures. 27
8
Lower Eyelids:
1. Incise skin lateral to canthus. 8. Open the incision as marked. Attach mosquito clamp to skin flap and pull it down. 9. Incise muscle, diuide it along a line parallel to fibers. 28
11 1 2
18. Remoue fat by pulling gently. 11. Trim excess skin from lower eyelid. 12. Close lower eyelid excision 29 Part Fiue
Forehead Lift
The aesthetics of the periorbital area is vital to the overall facial expression. Some of the most noticeable indications of aging which include drooping eyebrows, hooding over the eyes, forehead furrows and frown lines occur around this area on the upper third of the face.(Fig. 5-1)
Figure 5-1 Aging appearance accentuated with drooping eyebrows, hooding ouer the eges and forehead furrows 30 Generally, the eyebrows should arch smoothly on or partially on top of the supraorbital rim. Ideally, the medial side of the eyebrow should start at a vertical line extended through the lateral alar margin of the nose. The lateral section of the eyebrow should finish at an round line stretched through the nasal ala and the lateral canthus. The medial and lateral extensions of the eyebrow should lie in a horizontal plane. The summit of the eyebrow is at one-third at a the lateral , generally height on a vertical plane with the lateral junction of the iris and conjunctiva. The medial boundary of the brow should have a clubbed-head shape, with
tapering.22 the lateral segment gradually (Fig. 5-2)
Figure 5-2 The youthful appearance with ideal brow shape and location
22 Beeson Aesthetic of w.H. , Surgery the Aging Face (St. Louis, The C.V. Mosby Company, 1986), pp. 129-131 31 UJhile the usual facial rhytidectomy can rejuvenate the lower two thirds of the face and neck, the upper third is not improved. Forehead lift
,also known as a browlift, however, can reduce the aging signs of the upper third of the face. It works by the excision and modification of the problematic skin around the eyes and on the forehead, including the frontalis muscle. The operation will smooth the forehead, lift the upper eyelids and reduce frown lines.23 (Fig. 5-3)
Figure 5-3 During forehead lift, the extra skin and muscle of this area are lifted up and excised to smooth the forehead.
23 T.D. Rees, Aesthetic Plastic Surgery, v2, (Philadelphia, W.B. Saunders Company, 1980), pp.731 -735 32 SUAGICAL PAOCEDUAES
For most forehead lift patients, the incision will start approximately at the level of the ears and stretch across the top of the forehead. (Fig. 5-4 A,B)Scalp and forehead skin are carefully separated from the tissue underneath and lifted upwards. Then, the excess skin at the point of incision will be
excised.24
Figure 5-4 A&B Incision is made across the top of the head behind the hairline
24 j.c. Fisher, Manuel of Aesthetic Surgery, (NY, Springer-Verlag, 1985),pp 87-90 33 SUBGICAL TECHNIQUES ILLUSTHATEU
Cut the scalp and galea from ear to ear down to the periosteum beneath. Lift the scalp and galea with a skin hook. 34
/// / 1 1 I 1 1 I II I 1 1 u\\m 2. Separate the loose tissue connecting the galea to the periosteum 3. UJhen tissues are freed, pull entire forehead superiorward to eleuate the eybrows, eyelids and glabellar areas. Excise a portion of the corrugator and procerus
muscle 35
4. A horizontal ellipse of galea and frontalis muscle form the superior forehead ate remoued. This reduces the chances of recurrence of horizontal lines in the forehead. 36
5. Excess scalp is trimmed off. 6. Wound is closed with running suture. 37 Part Sin
Retin-R Treatment, Chemical Peel, Dermabrasion, and Laser Surgery
INTBODUCTION Associated with rejuuenating facial aesthetic surgeries such as facelift, brow lift and eye lift are Aetin-A treatment, chemical Peel, dermabrasion and laser surgery. These techniques are dermotologic surgeries which correct fine wrinkles and hide irregularities of skin surface texture. They do so by inducing wounds that change the epidermis, the papillary dermis and the upper portion of reticular dermis depending on how deep the would extends. UJhile Hetin-A cream and chemical peel burn the skin to eliminate wrinkles, dermabrasion sands the skin and laser surgery cooks the skin.(Herrera, 1996) The regenerated dermis are thicker and without fine wrinkles. (Fig. 6-1 H,B,C &U)
Figure 6-1 A Diagram of skin showing different lagers 38
j&
T ?
Figure 6-1 B Aetin-A cream and chemical peel both burn the epidermis of the skin to eliminate wrinkles 39
J])* K ^ T
-
L-~
Figure 6-1 C Dermabrasion sands the skin 40
Figure 6-1 D Laser surgery cooks the skin 41 Conclusion
This thesis was written with the intention to familiarize the general population with facial rejuuenating surgeries and the different options that are currently auailable. It was certainly an enjoyable experience for me to work on this project because I found the subject fascinating for it's ability to achieue the seemingly impossible task, which is to turn back the time on many faces.
After hauing finished this thesis, I belieue I would not hesitate to undergo aesthetic surgery to rejuuenate myself in the future when I need it. I think they are worth the effort because they do work to transform the aging appearances into more youthful looks. 42 Illustration Techniques
Figure 1-1, Carbon dust drawing was scanned into the computer first and color was then filled in using Hdobe Photoshop. The final print out was accented with color pencil. Labels made with Claris Works.
Figure 2-1 A,B,C, Pen and ink on satin design paper. Color was filled in on the back of paper with pastel powder.
Figure 2-2, Same as fig. 2-1
Figure 2-3, Same as fig. 2-1
Figure 2-4, Same as fig. 2-1
Figure 2-5, Same as fig.2-1
Figure 3-1, Same as fig. 1-1, incision line is made on print out with pen and ink.
Figure 3-2, Same as fig. 1-1
Figure 3-3, Same as fig. 1-1
Figure 3-4, Same as fig. 1-1
Figure 3-5, A, B, Pen and ink
Figure 4-1,A,B,C, Same as fig. 1-1
Figure 5-1, Same as fig. 1-1
Figure 5-2, Same as fig. 1-1 43 Figure 5-3, Same as fig. 1-1
Figure 5-4, Same as fig. 3-1
Figure 6-1, A, B, C, D Skin diagrams illustrated with gouach and color pencil. Photocopies made with Cannon color Herox machine. Surgical tools are illustrated with pen and ink.
All surgical technique illustrations are made with either carbon dust or pen and ink. 44 BIBLIOGRAPHY
Beeson, UJ. H,& E. Gaylon McCullough, (1986), aesthetic Surgery of the Rging Face, St. Louis, Toronto, The C. U. Mosby Company
Edgerton, M.T., & M.UJ. Langman,(1 982) Psychiatric Considerations. In E.H. Curtiss, Male aesthetic Surgery, pp. 17-38, St. Louis, The C.U. Mosby Company
Ellison, J. ,(1978) Life's Second Half-The Pleasures of Rging, Old Greenwich, Connecticut, The Deuin- Adair Company
Fisher, J. C, (1985) Jose Guerrerosantos, & Matthew Gleason, Manual of Resthetic Surgery, New Vork, Berlin, Heidelberg, Tokyo, Springer-Uerlag
Goin, J.M. & M.K. Goin, (1981) Changing the Body: Psychological Effects of Plastic Surgery , Baltimore, Williams & UJilkens.
Goin, J.M. & M.K. Goin, (1986) Psychological Effects of Aesthetic Facial Suryery. Rduances in Psychosomatic Medicine, 15, pp 84-107.
Habal, M.B. (1996), UJhat's New In Plastic Suryery, Clinics in Plastic Surgery, U23, #1, Philadelphia, London, Toronto, Tokyo, UJ.B. Saunders Company
Marcus, P. (1984) Psychological Aspects of Cosmetic Rhinoplasty. British Journal of Plastic Suryery, 37, 313-318 45 Pruzinsky, T., (1988) Collaboration of Plastic Surgeon and Medical Psychotherapist : Electiue Cosmetic Surgery. Medical Therapy: Rn International Journal, I, 1-13
Aees, T. D. (1980) Resthetic Plastic Suryery, I & II, Philadelphia, London, Tokyo, UJ.B. Saunders Company
Stegman, S.J., Theodore A. Tromouitch, & Aichard G. Glogau, 2nd ed. (1990), Cosmetic Dermatoloyic Surgery, Chicago, London, Boca Baton, Year Book Medical Publishers, INC.
Turabian, K.L. 5tn ed. (1986) R Manual for Writers of Term Papers, Theses, and Dissertations, Chicago, London, The Uniuersity of Chicago Press
Yousif, N.J., & D. L. Larson, (1995) Surgery of the Midface and Nasolabial Fold, Clinics in Plastic Suryery, U.22, #2, Philadelphia, London, Toronto, Sydney, Tokyo, UJ.B. Saunders Company